`Troubling' Rise in Preschoolers' Use of Psychiatric Drugs

Erica Goode, New York Times

Published
4:00 am PST, Wednesday, February 23, 2000

In a finding that medical experts called "troubling" and "very surprising," researchers reported today that the number of preschoolers taking stimulants, antidepressants and other psychiatric drugs rose sharply from 1991 to 1995.

The use of stimulants -- most commonly methylphenidate, better known by the trade name Ritalin -- increased twofold to threefold for children ages 2 through 4 enrolled in two state Medicaid programs and one health maintenance organization in the Northwest, the researchers found.

The number of children receiving prescriptions for antidepressants doubled in the Medicaid programs. The use of clonidine, a blood pressure drug gaining popularity as a treatment for attention disorders, also jumped among the group of more than 200,000 children studied.

The numbers are disturbing because little is known about the safety or efficacy of the medications on children under age 5, and because nonmedical factors might be influencing the frequency with which they are prescribed.

Although researchers have known for some time that such drugs increasingly are being prescribed for older children, the study, which appears in today's issue of the Journal of the American Medical Association, is the first to document an increase among children under 5.

"This seems to support the anecdotes that more U.S. children are receiving a diagnosis and treatment for attention deficit hyperactivity disorder in the late 1990s than ever before," said Dr. Julie Magno Zito, an associate professor of pharmacy and medicine at the University of Maryland and lead author of the study.

Previous studies have shown significant increases in the use of stimulants and antidepressants to treat children ages 5 to 19. In a smaller 1998 study of Medicaid enrollees in Michigan, researchers found that of 223 children under age 4 who were identified as having attention deficit hyperactivity disorder, 57 percent received at least one drug to treat the condition.

Although the total number of very young children in the latest study who received prescriptions for the drugs was small, 1 percent to 1.5 percent, the increase is cause for concern, the researchers said, because research on the safety and effectiveness of the drugs, scant for older children, is virtually nonexistent for preschoolers.

"We don't have any benchmarks to know if this is or is not a problem," Zito said.

Dr. Steven Hyman, director of the National Institute of Mental Health, said he was "more than shocked" by the findings. The use of psychiatric drugs in young children, he said, is "an area of enormous concern," and one that Hyman has made a priority in the institute's funding of research.

"We clearly need clinical trials of safety and efficacy for both pharmacological and psychosocial treatments in young children," Hyman said.

At the same time, he said, he is sympathetic "to the intense need to do something for children who really are so terribly sick that other means cannot control their behavior."

UNCERTAIN EFFECTS ON KIDS

Because the researchers did not track the diagnoses given to the children or the training of the professionals who prescribed the drugs, the reasons for the increases are not clear.

But experts speculate that the reasons might include the reluctance of HMOs and subsidized medical care programs to pay for counseling or other treatments that did not involve drugs; the pressures from parents and schools to diagnose attention deficit hyperactivity disorder in children; the rise of drugs as the preferred mode of treatment; and the fact that most prescriptions in subsidized settings are written by primary care doctors rather than specialists.

Few of the drugs, Zito and other experts pointed out, are approved by the Food and Drug Administration for treating children of preschool age. The package insert for methylphenidate, for example, carries a warning against prescribing the drug to children under 6.

While prescribing drugs for purposes not approved by the FDA, called off-label prescribing, is both legal and common in the treatment of older patients, the practice raises more difficult issues in young children.

SYMPTOMS VS. NORMAL BEHAVIOR

When a doctor prescribes a drug off-label for a child, Zito said, parents "should be aware that they are entering an area of uncertainty."

The symptoms of emotional or behavioral problems displayed by children under 5 may be different from those exhibited by older children, and diagnosis of such conditions in preschoolers is iffy at best. As Dr. Joseph Coyle, chairman of psychiatry at Harvard Medical School, said, the normal behavior of many children ages 2 and 3 looks a lot like attention deficit hyperactivity disorder.

"It is not really clear that children this young could meet the diagnostic criteria for either attention deficit hyperactivity disorder or depression," Zito said, "and those are the probable diagnoses given to justify the use of stimulants, clonidine and antidepressants."

Even more worrisome, experts said, is that little is known about the effects of antidepressants, stimulants and other psychoactive drugs on brain development.